Health inspection·May 10, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for five of five reviewed (Residents 10, 21, 50, 56, and 58). Residents Affected - Some Findings include: Review of Resident 10's clinical records revealed Resident 10 was admitted to the facility with a diagnosis of left sub gluteal abscess. The resident had an order for IV (Intravenous- a medication administered through a needle or tube inserted into a vein) antibiotics. Observation conducted on March 7, 2024, at 11:00 a.m., revealed a central line catheter to Resident 10's right upper chest. Observation conducted of Resident 10's room on the first three days of the survey failed to reveal evidence of EBP (Enhanced Barrier Precautions) signage or PPE (Personal Protective Equipment). Observation conducted on May 10, 2024, at 11:01 a.m., revealed Resident 21 had a pressure ulcer to the sacrum. Continued observation revealed resident had an indwelling foley catheter (flexible tube inserted into the bladder for removing fluid). An observation of Resident 21's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 50's clinical record revealed diagnosis list includes a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Observation conducted of Resident 50's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 56's clinical record revealed diagnosis list including but not limited to Gastrostomy Tube. Observation conducted of Resident 56's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 58's clinical records revealed the resident had an indwelling Foley catheter. Page 1 of 2 395974 395974 05/10/2024 Monticello House 1048 W Baltimore Avenue Media, PA 19063

F 0880 Level of Harm - Minimal harm or potential for actual harm Observation conducted of Resident 58's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE information regarding the facility's EBP process/procedures. Interview with non-licensed Employees E3 and E4 was conducted on May 10, 2024. Both employees were unable to provide explanation of Enhanced Barrier Precautions and how it relates to residents. Residents Affected - Some An interview with the Director of Nursing on May 10, 2024, at 12:30 p.m., was conducted. The DON reported that the facility had not implemented the Enhanced Barrier Precaution process and was still in the process of educating staff. The above information was presented to the Nursing Home Administrator on May 10, 2024, at 1:45 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395974 Page 2 of 2